Hisi Ext #3

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? A. A family member of a client with dementia who has been missing for five hours. B. A client with schizophrenia who wants to stop taking the medications. C. The parent of a child who was involved in a physical fight at school today. D. A client diagnosed with depression who is experiencing sexual dysfunction.

A. A family member of a client with dementia who has been missing for five hours. Rationale: The immediate safety of the client is at risk. A person with dementia who is missing poses a potential danger to themselves due to confusion and the inability to navigate safely in their environment.

A client tells the nurse of concerns about possibly having a stomach ulcer because the client is experiencing heartburn and a dull gnawing pain that is relieved by eating. Which is the best response by the nurse? A. Encourage the client to obtain a complete physical exam, as these symptoms are consistent with an ulcer. B. Advise the client to seek immediate medical evaluation and treatment for these symptoms. C. Instruct the client that these mild symptoms can generally be controlled with changes in the diet. D. Assure the client that the symptoms may only reflect reflux, since ulcer pain is not relieved by food.

A. Encourage the client to obtain a complete physical exam, as these symptoms are consistent with an ulcer. Rationale: Symptoms of heartburn and pain relieved by eating can indeed be consistent with an ulcer, and a complete physical exam can help diagnose the condition and rule out other causes.

The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? A. Engage the client in non-threatening conversations. B. Encourage the client's family to visit more often. C. Schedule a daily conference with the social worker. D. Encourage the client to participate in group activities.

A. Engage the client in non-threatening conversations. Rationale: Engaging in non-threatening conversations can help the client feel more comfortable and may encourage communication, which is crucial for clients who are withdrawn due to depression.

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next? A. Measure vital signs and telemetry pattern. B. Palpate and compare pedal pulse volumes. C. Measure post-procedure intake and output. D. Remove the dressing and observe the site.

A. Measure vital signs and telemetry pattern. Rationale: After cardiac catheterization, monitoring the client's vital signs and telemetry pattern is crucial, especially when symptoms like weakness and dizziness are reported. These symptoms could indicate serious complications such as bleeding, arrhythmia, or cardiac tamponade. Monitoring vital signs can help detect hypotension, hemorrhage, or other hemodynamic instabilities. Telemetry is crucial for detecting arrhythmias that may require immediate intervention.

On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for the family. Which information is most important for the nurse to obtain? A. What drugs the client used for the suicide attempt. B. When the client last took drugs for bipolar disorder. C. Whether the client ever attempted suicide in the past. D. Which family member has the client's suicide note.

A. What drugs the client used for the suicide attempt. Rationale: Knowing the type and amount of drugs ingested is critical for immediate medical intervention and treatment.

Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)? A. Reduce risk for infection. B. Achieve satisfactory pain control. C. Obtain adequate rest and sleep. D. Improve stress management skills.

B. Achieve satisfactory pain control. Rationale: Achieving satisfactory pain control is the primary goal in the management of DJD to improve the client's quality of life and functional ability.

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching? A. Washing for a total of 20 seconds. B. Turning the water off using bare hands. C. Holding hands below elbows when rinsing. D. Lathering using a circular movement.

B. Turning the water off using bare hands. Turning the water off using bare hands after washing can re-contaminate the hands. The CDC recommends using a paper towel to turn off the tap to avoid re-contamination.

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan? A. Eat a high-protein diet. B. Weigh every morning. C. Perform range of motion exercises. D. Limit fluid intake to 1,500 mL daily.

B. Weigh every morning. Rationale: Weighing every morning allows for monitoring of fluid retention, which is a key aspect of managing heart failure.

The nurse is caring for a client with elevated parathyroid hormone levels. Which safety precaution should the nurse include in the plan of care? A. Hypothermia. B. Aspiration. C. Falls. D. Suicide.

C. Falls. Rationale: Falls are a significant risk due to potential muscle weakness, skeletal fragility, and possible neuromuscular symptoms caused by hypercalcemia.

For a client who has undergone surgery to repair a retinal detachment in the left eye, which intervention should the nurse implement during the postoperative period? A. Obtain vital signs every 2 hours during hospitalization. B. Encourage deep breathing and coughing exercises. C. Provide an eye shield to be worn while sleeping. D. Teach a family member to administer eye drops.

C. Provide an eye shield to be worn while sleeping. Rationale: Providing an eye shield for sleep helps to protect the eye from accidental rubbing or pressure, which is critical after retinal surgery.

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful? A. "Is there any particular reason why you think this is your fault?" B. "You didn't do anything wrong." C. "With surgery, your baby should have a full recovery." D. "This must be a very difficult time for you."

D. "This must be a very difficult time for you." Rationale: Acknowledging the parent's feelings and the difficulty of the situation provides emotional support and validation without assigning blame or making promises about the outcome.

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse? A. Elevated blood pressure. B. Rapid, irregular heart rate. C. Swollen feet and ankles. D. Blood-tinged sputum.

D. Blood-tinged sputum. Rationale: Blood-tinged sputum indicates hemoptysis, which can be a sign of pulmonary edema or other serious complications requiring immediate intervention. This symptom is the most urgent and could signify a potentially life-threatening condition.

What conditions are most likely to respond to treatment with antihistamines? Select all that apply. A. Allergic rhinitis. B. Otitis media. C. Myocarditis. D. Bronchitis. E. Contact dermatitis.

A. Allergic Rhinitis E. Contact Dermatitis Rationale: A. Allergic rhinitis is a common condition that responds well to antihistamines, which can alleviate symptoms such as sneezing, runny nose, and itching. E. Contact dermatitis, which is an allergic skin reaction, can be treated with antihistamines to relieve itching and rash.

A nurse is caring for a client who reports having run out of aspirin a week ago and has been taking ibuprofen as a substitute. Which information should the nurse obtain from the client first? A. The reason for taking the aspirin. B. The dosage of ibuprofen taken. C. The amount of pain control achieved. D. The presence of gastric pain.

A. The reason for taking the aspirin. Rationale: Understanding the reason for taking aspirin is crucial because it could be for a chronic condition that requires antiplatelet action, which ibuprofen does not provide. Aspirin is often prescribed for its antiplatelet effect to prevent blood clots, while ibuprofen is primarily used for pain and inflammation.

A 22-year-old client is admitted to the hospital in diabetic ketoacidosis (DKA). The client's parent is insisting on knowing the laboratory test results. Which is the best response for the nurse to provide? A. "The healthcare provider will share this information with you." B. "I can only give medical information to your child because the client is an adult." C. "I'm sorry, but your child's medical information is none of your business." D. "I can give you those results as soon as I get them back from the lab."

B. "I can only give medical information to your child because the client is an adult." Rationale: This statement is factually correct; however, it may come across as dismissive and does not guide the parent on how to obtain the information they are seeking.

A nurse is caring for a client who has been prescribed parenteral lidocaine. Before administering the medication, the nurse should review the medical record for which condition? A. Glaucoma. B. Heart block. C. Gastric ulcers. D. Diabetes mellitus.

B. Heart block. Rationale: Heart block is a type of arrhythmia where the electrical signal is delayed or blocked entirely. Since lidocaine affects cardiac conduction, it is crucial to review the medical record for heart block before administration.

An older adult client with a history of heart failure is admitted to the medical unit after falling at home and has become increasingly confused. The client's spouse is designated as the client's power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first? A. Fall at home as the reason for admission. B. Increasing confusion of the client. C. Client's healthcare power of attorney. D. Currently prescribed medications.

B. Increasing confusion of the client. Rationale: Increasing confusion can indicate a change in the client's condition and may require immediate intervention, making it the priority in SBAR communication.

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide? A. Discuss that partners without similar symptoms may not be infected. B. Instruct the client on the importance of notifying sexual partners. C. Notify that persons with STIs are reported to local health departments. D. Provide counseling that most contraceptives protect against

B. Instruct the client on the importance of notifying sexual partners. Rationale: Notifying sexual partners is crucial for public health and the prevention of further transmission of STIs.

The nurse is caring for a client with a history of type 2 diabetes mellitus and hypertension who arrives at the clinic for a scheduled visit. Which finding requires further follow-up by the nurse?Creatinine: Female: [0.5 to 1.1 mg/dL (44 to 97 µmol/L)], Male: [0.6 to 1.2 mg/dL (53 to 106 µmol/L)] A. Blood pressure 130/80 mm Hg. B. Serum creatinine 1.6 mg/dL (141.44 µmol/L). C. Dark yellow urine. D. Difficulty staying asleep.

B. Serum creatinine 1.6 mg/dL (141.44 µmol/L). Rationale: A serum creatinine of 1.6 mg/dL is above the normal range for both males and females, indicating possible kidney dysfunction, which requires further follow-up.

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care? A. Right lower abdominal pain. B. Peripheral neuropathy. C. Confusion. D. Depression.

C. Confusion. Rationale: Confusion is a primary symptom of Wernicke's syndrome and should be used in planning the client's care, as it indicates acute encephalopathy and the need for immediate treatment with thiamine.

The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide? A. Cool and shake the bottle before administering the drops. B. Insert the tip of the dropper into the canal of the ear. C. Pull the pinna up and back to administer the drops. D. Administer the drops with the head held upright.

C. Pull the pinna up and back to administer the drops. Rationale: Pulling the pinna up and back in adults helps to straighten the ear canal, allowing for proper delivery of the medication.

The client is a 38-year-old male who was admitted from emergency department (ED) with five day worsening respiratory symptoms. Has a productive cough and difficulty breathing. Oral temperatures to 102 °F (38.9 °C) which had been responding to antipyretics. Chest x-ray identifies bilateral lower lobe pneumonia. The nurse is planning care for the client Potential conditions A. Pneumothorax B. Hypoventilation C. Atelectasis D. Hypoxia Actions to take A. increase iv fluid to prevent dehydation B. raise HOB C. Begin broncodilator nebulization D. change to face mask for o2 delivery Parameters to monitor A. lung sounds B. changes in loc C. O2 saturation D. Heart rhythm

Condition Hypoxia Actions to take Raise the head of the bed Change to face mask for oxygen delivery Parameters to monitor Lung sounds oxygen saturation

A nurse is caring for a client with binge eating disorder. Which goal should the nurse establish first with the client? A. Obtain satisfaction with appearance. B. Achieve steady weight loss. C. Institute an exercise plan. D. Regulate food portions.

D. Regulate food portions. Rationale: Regulating food portions is essential for reducing the frequency and volume of binge eating episodes, which is the immediate concern in binge eating disorder management.

The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes mellitus. He has a history of depression, which is treated with paroxetine 10 mg PO every day. The client also discloses that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's body mass index (BMI) is 28 kg/m2. understanding vs nonunderstanding ? A. "If I make the changes we talked about, 1 will not get type 2 diabetes. B""I can never eat sugar again." C. "If my fasting blood sugar is less than 100 mg/dL (5.6 mmol/L) next time, 1 can go back to my usual eating habits."" D.Making these changes will also help me avoid other chronic health conditions." E."If I have symptoms like increased thirst and urination, I should come in and get my blood sugar checked

Understanding B. "I can never eat sugar again." D. "Making these changes will also help me avoid other chronic health conditions. E."If I have symptoms like increased thirst and urination, I should come in and get my blood sugar checked NO understanding A. If I make the changes we talked about, 1 will not get type 2 diabetes C. If my fasting blood sugar is less than 100 mg/dL (5.6 mmol/L) next time, 1 can go back to my usual eating habits.

Twenty minutes after the onset of symptoms, an adult client presents to the emergency department with slurred speech and right-sided weakness. After a computerized tomography (CT) scan reveals a non-hemorrhagic stroke, the nurse administers alteplase. Which assessment finding warrants immediate intervention? A. Headache with blurred vision. B. Lower extremity edema. C. Paroxysmal supraventricular tachycardia. D. Frequent premature ventricular contractions.

A. Headache with blurred vision. Rationale: A headache with blurred vision following alteplase administration could indicate intracranial hemorrhage, which requires immediate intervention.

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take? A. Move the client to a private room, keep the door closed, and initiate droplet precautions. B. Place the nasal swab specimen for COVID-19 directly into a biohazard bag. C. Assist the client to recall everyone possibly exposed since the onset of symptoms. D. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.

A. Move the client to a private room, keep the door closed, and initiate droplet precautions. Rationale: This is the most immediate and important action to take to prevent the potential spread of COVID-19, especially in a healthcare setting where there is a risk of infecting others.

An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement? A. Obtain a clean, voided urine specimen for analysis. B. Evaluate the client's response to bladder training efforts. C. Provide protective undergarments for the client. D. Encourage increased fluid intake for 24 hours.

A. Obtain a clean, voided urine specimen for analysis. Rationale: Obtaining a urine specimen is essential for analyzing possible infections or other abnormalities that could be causing urinary incontinence.

A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion? A. Urinary output of 30 to 60 ml/hr B. Magnesium Level C. Size of the Iv catheter D. Serum glucose level

A. Urinary output of 30 to 60 ml/hr Rationale: Before administering IV fluids containing potassium chloride, it is crucial to ensure that the client has adequate urinary output, typically between 30 to 60 mL/hr. This indicates good kidney function, which is necessary for the excretion of potassium to prevent hyperkalemia, a potentially life-threatening condition.

When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? Select all that apply. A. Sloughing tissue around wound edges. B. Loss of sensation to the left lower extremity. C. Weeping serosanguineous fluid from wounds. D. Reporting increased pain and pressure. E. Change in the quality of the peripheral pulses.

B. B. Loss of sensation to the left lower extremity. Loss of sensation could indicate nerve damage or developing compartment syndrome, which is a medical emergency requiring immediate intervention to prevent permanent damage. D. Reporting increased pain and pressure. Increased pain and pressure are signs of potential compartment syndrome or infection, both of which require prompt assessment and possible intervention. E.Change in the quality of the peripheral pulses. A change in the quality of peripheral pulses may indicate vascular compromise, which requires immediate intervention to restore circulation and prevent tissue death.

The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client? A. Remove dentures or other oral appliances. B. Lift and lock the side rails in place. C. Apply the client's positive airway pressure device. D. Elevate the head of the bed to a 45-degree angle.

C. Apply the client's positive airway pressure device. Rationale: Applying the client's positive airway pressure device is the most important intervention. Opioids can depress respiration, and for a client with OSA, ensuring the airway is patent and supported by a positive airway pressure device is crucial to prevent respiratory complications.

A client with 50% full-thickness burns has received fluid resuscitation for the past 24 hours. Which assessment warrants immediate intervention by the nurse? A. Average urine output of 28 mL/hour. B. Vesicular bibasilar breath sounds. C. Inspiratory and expiratory bilateral crackles. D. Central venous pressure of 12 mm Hg.

C. Inspiratory and expiratory bilateral crackles. Choice C: Inspiratory and expiratory bilateral crackles Rationale: Crackles, also known as rales, are abnormal lung sounds that indicate the presence of fluid in the alveoli. Bilateral crackles heard during both inspiration and expiration suggest significant pulmonary edema or acute respiratory distress syndrome (ARDS), which can be life-threatening and requires immediate intervention.

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client? A. The nurse will encourage the client to walk thirty minutes every day. B. The client will monitor blood glucose and blood pressure after each meal. C. The client's daily blood pressure will be less than 140/80 mm Hg this month. D. The client's blood pressure readings will be less than 160/90 mm Hg.

C. The client's daily blood pressure will be less than 140/80 mm Hg this month. Rationale: Maintaining a daily blood pressure of less than 140/80 mm Hg is a specific and measurable outcome that can help manage symptoms of cardiovascular disease and prevent complications.

After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)? A. Initiate teaching for client care after discharge. B. Evaluate and update plans of care for clients. C. Begin initial sterile wound care for surgical clients. D. Validate prescribed intravenous flow rates.

D. Validate prescribed intravenous flow rates. Rationale: Validating prescribed intravenous flow rates is a task that can be delegated to a practical nurse, as it involves monitoring and ensuring that the flow rates are set according to the prescribed orders, which is within the practical nurse's scope of practice.

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety? A. Assess for discomfort when the procedure is completed. B. Instruct the client to keep hands under the sterile field. C. Pour cleansing solution onto the sterile cloth field. D. Verify that the client has given informed consent.

D. Verify that the client has given informed consent. Rationale: Verifying informed consent is crucial for client safety to ensure that the client understands the procedure and agrees to it, especially when the client is confused.

A client who weighs 110 lbs has received a prescription for dalteparin, 150 units/kg to be administered subcutaneously daily for 4 months. The medication is available in a 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Please enter the numerical value only.)

0.3 Rationale: Step 1: Convert the client's weight from lbs to kg using the conversion factor you provided (1 kg = 2.2 lbs). So, 110 lbs × (1 kg ÷ 2.2 lbs) = 50 kg Step 2: Calculate the daily dosage of dalteparin in units using the prescription (150 units/kg). So, 50 kg × 150 units/kg = 7500 units Step 3: Determine how many mL of the medication this dosage corresponds to using the information on the syringe (7500 units/0.3 mL). So, 7500 units × (0.3 mL ÷ 7500 units) = 0.3 mL

A client has received a prescription for loratadine suspension, 10 mg to be taken orally once a day. The bottle is labeled as "Loratadine for Oral Suspension, USP 5 mg per 5 mL." How many teaspoons should the nurse instruct the client to take? (Please enter the numerical value only.)

2 tsp Rationale: We need to find out how many mL contain 10 mg of loratadine. Since 5 mg of loratadine is in 5 mL, we can set up a proportion to find out how many mL contain 10 mg. So, 5 mg is to 5 mL as 10 mg is to X mL. This gives us the equation: (5 mg ÷ 5 mL) = (10 mg ÷ X mL) Step 2: Solving for X gives us X = (10 mg × 5 mL) ÷ 5 mg Step 3: Simplifying gives us X = 10 mL So, the client needs to take 10 mL of the loratadine suspension to get a dose of 10 mg. Now, we need to convert this volume in mL to teaspoons, using the conversion factor you provided (1 teaspoon = 5 mL). Step 4: We set up the conversion as follows: 10 mL × (1 tsp ÷ 5 mL) Step 5: Simplifying gives us 2 tsp So, the nurse should instruct the client to take 2 teaspoons of the

The healthcare provider has prescribed heparin, 3 units/kg to be administered via IV push for a client who weighs 175 pounds. The vial is labeled as "100 units/mL." How many mL should the nurse administer? (Please enter the numerical value only. If rounding is required, round to the nearest tenth.)

2.4 Rationale: Step 1: Convert the weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, the weight in kg is: 175 lbs ÷ 2.2 = 79.55 kg Step 2: Calculate the total units of heparin needed. The prescription is for 3 units/kg, so: 3 units/kg × 79.55 kg = 238.65 units Step 3: Calculate the volume of heparin to administer. The vial is labeled as "100 units/mL", so: 238.65 units ÷ 100 units/mL = 2.39 mL So, the nurse should administer approximately 2.4 mL of heparin

A client has received a prescription for a fluid bolus of 0.9% sodium chloride, 200 mL to be infused in 30 minutes. How many mL/hr should the nurse program the infusion pump to deliver? (Please enter the numerical value only.) The question is asking for the rate at which the infusion pump should be programmed to deliver a fluid bolus of 200 mL in 30 minutes. This can be calculated using the formula for rate which is volume divided by time.

400 Rationale: Step 1: Convert the volume of fluid to be infused from mL to L (since the rate is usually measured in mL/hr): 200 mL = 200 mL (No conversion needed as the volume is already in mL) Step 2: Convert the time for infusion from minutes to hours (since the rate is usually measured in mL/hr): 30 minutes = 30 ÷ 60 = 0.5 hours Step 3: Calculate the rate (volume ÷ time): Rate = Volume ÷ Time Rate = 200 mL ÷ 0.5 hours Rate = 400 mL/hr The nurse should program the infusion pump to deliver at a rate of 400 mL/hr.

A school-aged client is receiving vancomycin, 400 mg IV every 6 hours for a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection. The medication is diluted in a 100 mL bag of 0.9% sodium chloride with instructions to infuse over one and a half hours. How many mL/hour should the nurse program the infusion pump? (Please enter the numeric value only. If rounding is required, round to the nearest whole number.

67 Rationale: Step 1: Convert the volume of fluid to be infused from mL to mL (since the rate is usually measured in mL/hr): 100 mL = 100 mL (No conversion needed as the volume is already in mL) Step 2: Convert the time for infusion from hours to hours (since the rate is usually measured in mL/hr): 1.5 hours = 1.5 hours (No conversion needed as the time is already in hours) Step 3: Calculate the rate (volume ÷ time): Rate = Volume ÷ Time Rate = 100 mL ÷ 1.5 hours Rate = 66.67 mL/hr

Nurses working on a surgical unit are concerned about a physician's treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client's response. To resolve this problem, the nurses should perform these actions in which order? (Arrange from the first action on top to the last on the bottom.) A. Document concerns and report them to the charge nurse B. Talk to the physician as a group in a non-confrontational manner C. Submit a written report to the Director of Nursing D. Contact the Hospital's Chief of Medical Services E. File a format complaint with the state medical board

A, B, C, D, E Rationale: Choice A reason: The first step is to document the concerns for an accurate record and report them to the charge nurse to address the issue internally within the unit. Choice B reason: If the issue is not resolved at the unit level, the next step is to discuss the matter with the physician directly as a group, which can lead to a resolution without escalating the situation. Choice C reason: Should the problem persist, submitting a written report to the Director of Nursing is appropriate to involve higher management and seek further action. Choice D reason: If the issue remains unresolved after involving the Director of Nursing, contacting the hospital's Chief of Medical Services is the next step to escalate the matter within the hospital's administrative structure. Choice E reason: As a last resort, if all internal avenues have been exhausted and the problem persists, filing a formal complaint with the state medical board is necessary to address potential violations of professional conduct.

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first? A. Activate the lockdown procedure. B. Match ID bands of all infants and mothers on the unit. C. Ask the mother if any visitors were expected to arrive. D. Determine if the newborn is in the nursery.

A. Activate the lockdown procedure. Rationale: The immediate activation of the lockdown procedure is critical in the event of a suspected infant abduction, as it helps to secure the facility and prevent the unauthorized removal of the infant.

One hour after arriving on the postoperative unit, a woman who received spinal anesthesia 5 hours ago is complaining of severe abdominal incisional pain. Her vital signs include oral temperature 99.0°F (37.2°C), heart rate 110 beats/minute, respiratory rate 30 breaths/minute, and blood pressure 160/90 mm Hg. The client's skin is pale, and the surgical dressing is dry and intact. Which intervention is most important for the nurse to implement? A. Administer an IV analgesic. B. Assess the IV site for patency. C. Provide a pillow for splinting. D. Place in a high-Fowler's position.

A. Administer an IV analgesic. Rationale: The priority is to manage the client's severe pain, which can be achieved through the administration of an IV analgesic. Effective pain management is crucial for postoperative recovery and can prevent complications related to increased pain, such as elevated heart rate and blood pressure.

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. Which action should the nurse take? A. Advise the UAP to resume positioning the client on schedule. B. Encourage the UAP to provide comfort care measures only. C. Assume total care of the client to monitor neurologic function. D. Assign a practical nurse to assist the UAP in turning the client.

A. Advise the UAP to resume positioning the client on schedule. Rationale: Turning the client from side to side is a critical nursing intervention to prevent complications such as pressure ulcers, pneumonia, and other issues related to immobility. Even though the client has a "Do Not Resuscitate" (DNR) order, it does not mean that comfort and preventive care measures should be stopped. The nurse should advise the UAP to continue with the scheduled positioning to ensure the client's comfort and prevent further complications.

The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use? A. Ask the client to describe the pain. B. Observe body language and movement. C. Identify effective pain relief measures. D. Provide a numeric pain scale.

A. Ask the client to describe the pain. Rationale: Asking the client to describe the pain is essential as it provides subjective information about the pain's quality, intensity, and impact on daily activities, which is crucial for assessing osteoarthritis pain.

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. What instruction(s) should the nurse include in the client's discharge teaching plan? Select all that apply. A. Avoid prolonged standing or sitting. B. Cross legs at the knee but not at the ankle. C. Continue wearing compression stockings. D. Use a recliner for long periods of sitting. E. Maintain the bed flat while sleeping.

A. Avoid prolonged standing or sitting C. Continue wearing compression stockings D. Use a recliner for long periods of sitting rationale: A. Prolonged standing or sitting can exacerbate symptoms of chronic venous insufficiency (CVI) by increasing venous pressure and promoting blood pooling in the legs. Movement helps to enhance venous return and reduce swelling. C. Compression stockings are a cornerstone in the management of CVI. They help to improve venous return, reduce swelling, and prevent blood from pooling in the legs. Compression stockings should be worn as prescribed, typically during the day and removed at night. D. Using a recliner can help elevate the legs above heart level, which reduces venous pressure and promotes venous return. This position can help alleviate symptoms of CVI.

A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take? A. Evaluate the effectiveness of this measure to stimulate client voiding. B. Recommend a complete bath to cleanse the perineal area more fully. C. Suggest contacting the healthcare provider for a prescription for catheter insertion. D. Instruct the PN that this technique promotes infection in elderly females.

A. Evaluate the effectiveness of this measure to stimulate client voiding. Rationale: Pouring warm water over the perineal area can stimulate the micturition reflex, which may help the client void. It is a non-invasive, first-line intervention to promote natural voiding in clients with urinary incontinence. The nurse should evaluate its effectiveness as it can be a simple yet effective method to assist the client.

The patient is a 3-year-old male with a history of ventricular septal defect. He was born vaginally at 35 weeks and was in the neonatal intensive care unit (NICU) for 3 weeks due to poor feeding. He lives with his parents and an older sibling, who has no medical conditions. The patient is here for a follow-up visit. ECHO results: Moderate ventricular septal defect, increased pulmonary blood flow Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal defect via cardiac catheterization. What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply. A.Obtain a history of allergic reactions B. Document lying, sitting, and standing blood pressures C. Perform a mini mental exam on the child D. Determine when the child last ate E. Locate and mark the pedal pulses F. Measure the child's height and weight

A. Obtain a history of allergic reactions Obtaining a history of allergic reactions is crucial because the child will be exposed to various substances during cardiac catheterization, such as contrast dye, which could potentially cause an allergic reaction. B.Document lying, sitting, and standing blood pressures Documenting lying, sitting, and standing blood pressures is important to assess for orthostatic hypotension, which could indicate volume depletion or cardiovascular problems that need to be addressed before the procedure. D. Determine when the child last ate Determining when the child last ate is essential because the child needs to have an empty stomach to reduce the risk of aspiration during sedation. E.Locate and mark the pedal pulses Locating and marking the pedal pulses is important to establish baseline data so that post-procedure, any changes in the strength or presence of these pulses can be quickly identified, indicating potential complications.

An older adult client is admitted for the repair of a broken hip. To reduce the risk of infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? Select all that apply. A. Teach the client to use an incentive spirometer every 2 hours while awake. B. Administer low molecular weight heparin as prescribed. C. Assess the pain level and medicate as needed, as prescribed. D. Maintain sequential compression devices while in bed. E. Remove the urinary catheter as soon as possible and encourage voiding.

A. Teach the client to use an incentive spirometer every 2 hours while awake. Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent postoperative pulmonary complications such as pneumonia. This intervention promotes lung expansion and clears secretions, reducing the risk of infection. E. Remove the urinary catheter as soon as possible and encourage voiding. Removing the urinary catheter as soon as possible and encouraging voiding reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal of the catheter minimizes the duration of exposure to potential pathogens, thereby reducing infection risk.

The client is a 3-year-old male with a history of ventricular septal defect (VSD). He was born prematurely at 35 weeks and spent 3 weeks in the neonatal intensive care unit (NICU) due to poor feeding. He resides with his parents and an older sibling, who has no medical conditions. The client is here for a follow-up visit. Echocardiogram (ECHO) today After the physician orders the echocardiogram, the nurse educates the parents about the procedure. For each statement below, indicate whether it shows understanding or a lack of understanding by the parents. After the physician orders the echocardiogram, the nurse educates the parents about the procedure. For each statement below, indicate whether it shows understanding or a lack of understanding by the parents. A. The echocardiogram is an invasive procedure B. I can show my child a movie or read him a book during the procedure. C.The echocardiogram is a painful proced

A. The echocardiogram is an invasive procedure.: NO UNDERSTANDING, B. I can show my child a movie or read him a book during the procedure.: UNDERSTANDING, C. The echocardiogram is a painful procedure.: NO UNDERSTANDING, D. The echocardiogram will produce an image of the structure of the heart.: UNDERSTANDING, E.Echocardiography uses sound waves to produce images.: UNDERSTANDING,

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with a possible methicillin-resistant Staphylococcus aureus (MRSA) infection. What intervention(s) should the nurse include in the plan of care? Select all that apply. A. Use standard precautions and wear a mask. B. Explain the purpose of a low bacteria diet. C. Institute contact precautions for staff and visitors. D. Send wound drainage for culture and sensitivity. E. Monitor the client's white blood cell count.

A. Use standard precautions and wear a mask. C. Institute contact precautions for staff and visitors. D. Send wound drainage for culture and sensitivity. E. Monitor the client's white blood cell count. Rationale: A. Standard precautions, including the use of masks, are essential to prevent the spread of MRSA, which can be transmitted through respiratory droplets. C. Contact precautions are critical for preventing MRSA transmission, as it can be spread by direct contact with the infected wound or contaminated surfaces. D. Sending wound drainage for culture and sensitivity is crucial to identify the specific strain of MRSA and determine the most effective antibiotic treatment. E. Monitoring the white blood cell count is important to assess the body's response to infection and the effectiveness of treatment.

Discharge instructions for the patient above with the bariatric surgery. What discharge education should the nurse provide? Select all that apply. A. walk frequent during recovery B. advance diet from clear liquids to full liquids C. anticipate weight loss will continue even with normal diet D. Beging taking supplements per the healthcare provider's orders E. expect immediate return of ovulation F. start with room temperature water G. encourage three large meals a day

A. Walk frequently during recovery. Walking frequently during recovery is essential for preventing blood clots, improving circulation, and aiding in the healing process. It is recommended for patients to start with short, frequent walks and gradually increase the distance as tolerated. This helps to enhance physical activity and supports weight loss maintenance post-surgery. B. Advance diet from clear liquids to full liquid. After bariatric surgery, patients are typically started on a clear liquid diet and then advanced to full liquids before progressing to pureed foods and eventually solid foods. This gradual progression is necessary to allow the stomach to heal and to avoid complications such as leaks or obstructions at the surgical site. D. Begin taking supplements per the healthcare provider's orders. Patients who have undergone bariatric surgery are at risk for nutritional deficiencies due to the reduced intake and absorption of nutrients. Therefore, taking prescribed vitamin and mineral supplements is crucial to prevent deficiencies and ensure adequate nutrition. F. Start with room temperature water. Starting with room temperature water can help prevent discomfort and gastrointestinal symptoms that may occur when drinking cold fluids after surgery. Room temperature fluids are generally better tolerated in the immediate postoperative period.

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory values should the nurse monitor? Select all that apply. A. White blood cell (WBC) count. B. Red blood cell (RBC) count. C. Serum potassium. D. Blood urea nitrogen (BUN). E. Sputum culture and sensitivity.

A. White blood cell (WBC) count E. Sputum culture and sensitivity Rationale: A. Monitoring the WBC count can help determine if the antibiotic is effectively treating an infection, as a decreasing count may indicate recovery. E. A sputum culture and sensitivity test can identify the causative bacteria and determine if the antibiotic is effective.

A 22-year-old female client is brought to the emergency department by her mother after the client became dizzy and fell. The mother says that the client has been away at college and is home for winter break. The client's mother is greatly concerned because while her daughter has always been thin and athletic, she has never seen her so skinny and emaciated. The client responds by telling her mother, "That is not true. You keep trying for force food down my throat even though it is obvious that I have so much weight to lose!" Which interventions are indicated to promote positive outcomes for the patient? Select all that apply. A. Allow for menu deviations. B. Set precise mealtimes. C. Encourage exercise. D. Monitor trips to the restroom. E.Provide family education on the condition. F. Weigh the patient twice weekly. G. Acknowledge feelings of anxiety.

A.Allow for menu deviations. Allowing for menu deviations can help accommodate the patient's preferences and encourage eating, which is crucial for recovery from emaciation. B. Set precise mealtimes. Setting precise mealtimes can provide structure and consistency, which may help the patient establish regular eating habits. Monitor trips to the restroom. Monitoring trips to the restroom is important to prevent purging behaviors, which can be a concern in patients with eating disorders. E. Provide family education on the condition. Providing family education on the condition is essential to ensure that the family understands the patient's needs and how to support her recovery. F. Weigh the patient twice weekly. Weighing the patient twice weekly can help monitor her progress and adjust the treatment plan as needed. G. Acknowledge feelings of anxiety. Acknowledging feelings of anxiety is important for addressing the psychological aspects of the patient's condition and promoting a supportive environment.

Day 1,1440 The client arrives on the medical surgical floor. Assessment Neurological Drowsy but wakes spontaneously. Oriented times 4. Cardiovascular WNL. Respiratory Breath sounds diminished in bilateral bases. Shallow breaths. Reported sleep apnea. Gastrointestinal/Genitourinary Indwelling urinary catheter in place. Urine clear yellow in appearance. Integumentary Abdominal incisions times 4 from laparoscopic procedure sealed with surgical glue. Musculoskeletal reported chronic knee pain. 5+ strength in bilateral upper extremities, 4+ strength in bilateral lower extremities. 5 nursing interventions are indicated for this client? A. apply sequential compression stockings when in bed. B. Maintain strict bedrest for 12 hours after surgery. C. Provide chilled beverages. D. Change position frequently. E. Encourage coughing and deep breathing. F. Observe for signs and symptoms of dumping syndrome. G. Keep client NPO

A.Apply sequential compression stockings when in bed. Applying sequential compression stockings when in bed is a recommended postoperative intervention for bariatric surgery patients. It helps prevent deep vein thrombosis (DVT) by promoting venous return and reducing venous stasis, which is particularly important in patients with obesity due to their increased risk for DVT. D. Change position frequently. Changing position frequently is an important postoperative intervention to prevent complications such as pressure ulcers and to promote lung expansion, especially in patients with obesity who are at higher risk for these issues. E. Encourage coughing and deep breathing. Encouraging coughing and deep breathing is essential after bariatric surgery to help clear the airways, prevent atelectasis, and improve oxygenation. This is particularly important for this patient who has a history of sleep apnea and reported diminished breath sounds postoperatively. F. Observe for signs and symptoms of dumping syndrome. Observing for signs and symptoms of dumping syndrome is relevant for bariatric surgery patients, as this syndrome can occur when food moves too quickly from the stomach to the small intestine. However, this is more of a long-term concern rather than an immediate postoperative intervention. H. Maintain head at 45-degree angle. Choice H reason: Maintaining the head at a 45-degree angle can help improve respiratory function by reducing pressure on the diaphragm, which is especially beneficial for patients with obesity and a history of sleep apnea, as in this case.

The patient is a 3-year-old male with a history of ventricular septal defect. He was born vaginally at 35 weeks and was in the neonatal intensive care unit (NICU) for 3 weeks due to poor feeding. He lives with his parents and an older sibling, who has no medical conditions. The patient is here for a follow-up visit. The nurse educates the parents on post discharge care for the child. What should the nurse include in post discharge care education? Select all that apply. Monitor for fever B. Give only clear liquids for several days C. Avoid any kind of bath or shower D. Keep a pressure dressing on the site for one week E. Alert the physician if the site bleeds or swells F. The child may take ibuprofen for pain

A.Monitor for fever Monitoring for fever is essential after cardiac procedures like the one described. Fever can be a sign of infection, which is a risk following any invasive procedure. Normal body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C) for a typical child, but it can be slightly lower in the morning and higher in the late afternoon and evening. E.Alert the physician if the site bleeds or swells Alerting the physician if the site bleeds or swells is crucial. Swelling or bleeding can indicate complications such as infection or hematoma formation. Parents should be instructed to look for any signs of abnormal discharge, redness, or increased pain, which could signify an infection. F. The child may take ibuprofen for pain The child may take ibuprofen for pain, but it should be under the guidance of a physician. Ibuprofen is an NSAID that can help with pain and inflammation. However, it's important to use the correct dosage and to ensure it doesn't interfere with any other medications the child may be taking.

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situation(s) to the school nurse? Select all that apply. A. Shaking that changes the child's handwriting legibility. B. Thirst and frequent requests for bathroom breaks. C. Refusal to complete written homework assignments. D. Bruises on both knees after the weekend. E. Sunburn with blisters on the face, arms, and hands.

A.Shaking that changes the child's handwriting legibility. B. Thirst and frequent requests for bathroom breaks. E. Sunburn with blisters on the face, arms, and hands. Rationale: A. Shaking that affects a child's handwriting could indicate a neurological issue or other medical conditions that require immediate attention. It's essential for teachers to report such observations to the school nurse for proper assessment and intervention. B. Excessive thirst and frequent urination can be signs of diabetes, especially in children. Early detection and management are crucial for the child's health, making it important for teachers to report these symptoms. E. Excessive thirst and frequent urination can be signs of diabetes, especially in children. Early detection and management are crucial for the child's health, making it important for teachers to report these symptoms.

The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes mellitus. He has a history of depression, which is treated with paroxetine 10 mg PO every day. The client also discloses that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's body mass index (BMI) is 28 kg/m2. Review H and P and laboratory results. What item(s) should be included in the treatment regimen for this client? Select all that apply. A. Weight reduction treatment B. Exercise planning Long-acting insulin D. Nutrition education E. Extra carbohydrates F. Oral antidiabetic G. Short acting insulin

A.Weight reduction treatment Weight reduction treatment is a modifiable risk factor for prediabetes. Losing a small amount of weight, around 5% to 7% of body weight, can significantly lower the risk of developing type 2 diabetes. For a 200-pound person, this means losing about 10 to 14 pounds. B. Exercise planning Exercise planning is crucial as it helps improve insulin sensitivity and glucose metabolism. The recommendation is at least 150 minutes per week of moderate-intensity physical activity, such as brisk walking or light cycling. D. Nutrition education Nutrition education is essential for managing prediabetes. A diet rich in fiber, whole grains, and non-starchy vegetables, and low in added sugars and saturated fats, can help manage blood glucose levels3. F. Oral antidiabetic Oral antidiabetic medications, such as metformin, may be prescribed to help lower blood glucose levels and improve insulin sensitivity in individuals with prediabetes.

The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning? A. An 8-year-old who lives in a housing project. B. A 2-year-old who plays on aging outdoor playground equipment. C. An adolescent who works part-time in a paint factory. D. A 10-year-old who has Type 1 diabetes mellitus.

B. A 2-year-old who plays on aging outdoor playground equipment. Rationale: A 2-year-old is at the highest risk due to their developmental stage, which includes frequent hand-to-mouth activity and the likelihood of playing in soil or dust that may be contaminated with lead.

On the second postoperative day, a client who had a colon resection is starting to eat and ambulate with assistance. Although the client has a prescription for an oral analgesic, they request that the PCA containing morphine be continued for one more day due to fear of pain. Which intervention is most important for the nurse to implement? A. Measure urinary output to ensure renal functioning. B. Administer the oral analgesic medication an hour before discontinuing the PCA pump. C. Monitor for a depressed respiratory rate. D. Teach about the need to progress to a high-fiber diet.

B. Administer the oral analgesic medication an hour before discontinuing the PCA pump. Rationale: Administering the oral analgesic before discontinuing the PCA allows for the medication to take effect, preventing breakthrough pain and addressing the client's fear of pain

A client is scheduled for an IV pyelogram today. The nurse instructs the client that the x-ray visualizes the kidneys, ureters, and bladder. Which information is most important for the nurse to gather before the client goes for the x-ray? A. Find out if the client can lie prone for the x-ray. B. Ask if the client has an allergy to shellfish. C. Determine the last time the client had a bowel movement. D. Inquire if the client has taken regularly scheduled medications.

B. Ask if the client has an allergy to shellfish. Rationale: Asking about a shellfish allergy is crucial because the contrast dye used in an intravenous pyelogram may contain iodine, which can cause an allergic reaction in individuals with shellfish allergies.

After a partial gastrectomy, in addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform to prevent respiratory complications? A. Promote full diaphragmatic excursion by massaging the back. B. Assist the client to a chair the day after surgery when the condition is stable. C. Note areas of atelectasis on the daily chest x-rays. D. Provide ice or oral liquids when the client passes flatus.

B. Assist the client to a chair the day after surgery when the condition is stable. Rationale: Assisting the client to sit in a chair encourages lung expansion and sputum clearance, which are crucial for preventing atelectasis and pneumonia.

A nurse is caring for a client who underwent an appendectomy 2 days ago and now reports sudden, unbearable pain in the left great toe. The client has a medical history of type 2 diabetes mellitus, gouty arthritis, and gastroesophageal reflux disease (GERD). Which instruction should the nurse include in the discharge teaching? A. eat high protein foods to achieve ideal body weight B. Avoid acetylaslincylic acid-containing medications C. Wrap joints with an elastic bandage when swollen D. Support joints in an extended position while resting

B. Avoid acetylsalicyclic acid-containing medications Rationale: Patients with gouty arthritis should avoid acetylsalicylic acid (aspirin) as it can lead to an increase in uric acid levels, potentially exacerbating gout attacks. Instead, medications that do not affect uric acid levels should be used for pain relief.

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings? A. Fat emboli. B. Deep vein thrombosis. C. Infection. D. Pulmonary embolism.

B. Deep vein thrombosis. Rationale: Deep vein thrombosis (DVT) is a common condition in immobile patients, and redness and swelling in the calf are classic signs.

The healthcare provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement? A. Tell the charge nurse about the prescribed placebo and refuse to administer it. B. Discuss ethical concerns about placebo use with the healthcare provider. C. Administer the placebo as prescribed when the client reports pain. D. Inform the client that the provider prescribed a placebo instead of pain medication.

B. Discuss ethical concerns about placebo use with the healthcare provider Rationale: Discussing ethical concerns with the healthcare provider is the most appropriate action as it addresses the potential breach of patient trust and informed consent associated with placebo use.

The patient is a 3-year-old male with a history of ventricular septal defect. He was born vaginally at 35 weeks and was in the neonatal intensive care unit (NICU) for 3 weeks due to poor feeding. He lives with his parents and an older sibling, who has no medical conditions. The patient is here for a follow-up visit. What can the nurse do to help the parents decrease their anxiety? Select all that apply. A. Tell the parents that the procedure is 100% effective and safe B. Provide the parents with ideas about how to make their child feel better after the procedure C. Find a comfortable area for the parents to wait that is close to the procedure area D. Limit visitation as long as the parents are anxious E. Do not give any specifics on the amount of time the procedure will take

B. Provide the parents with ideas about how to make their child feel better after the procedure Providing the parents with ideas about how to make their child feel better after the procedure can be comforting and can help them feel more involved and prepared for post-procedure care. C. Find a comfortable area for the parents to wait that is close to the procedure area Finding a comfortable area for the parents to wait that is close to the procedure area can help reduce their anxiety by keeping them informed and involved in the process.

The client is a 40-year-old gravida 2, para 2 at 36 weeks with moderate pre-eclampsia. On initial assessment client presented with a blood pressure of 178/100 mm Hg, edema to the upper and lower extremities, severe headache, and pulmonary edema. Her urine sample showed 2++ proteinuria. The client was admitted to the unit with orders to begin magnesium sulfate and maintain continuous fetal monitoring. The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply. A. Prepare for a cesarean delivery B. Administer calcium gluconate C. Obtain blood pressure Stop infusion of magnesium E. Increase IV fluids F. Administer oxygen G. Obtain serum magnesium level H. Make preparations to prevent cardiac arrest

B.Administer calcium gluconate Administering calcium gluconate is appropriate if there are signs of magnesium sulfate toxicity, as it acts as an antidote. The patient's decreased level of consciousness and absent DTRs may suggest magnesium toxicity, making this a correct intervention. C. Obtain blood pressure Obtaining blood pressure is a standard and ongoing requirement for monitoring a pre-eclampsia patient, especially after noting a significant drop in blood pressure from 170/98 mm Hg to 118/78 mm Hg, which could indicate an overcorrection or other issues. F. Administer oxygen Administering oxygen is correct as the patient's oxygen saturation has dropped from 98% to 93%, and the goal is to maintain it above 96% as per the physician's orders. G. Obtain serum magnesium level Obtaining serum magnesium level is correct because it is necessary to monitor for signs of magnesium sulfate toxicity given the patient's symptoms of decreased LOC and absent DTRs. H. Make preparations to prevent cardiac arrest Preparing to prevent respiratory or cardiac arrest is correct as the patient has signs that may suggest impending magnesium sulfate toxicity, which can lead to respiratory depression or cardiac arrest.

The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes mellitus. He has a history of depression, which is treated with paroxetine 10 mg PO every day. The client also discloses that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's body mass index (BMI) is 28 kg/m2. Review H and P, nurse's note, and laboratory results. What other nutritional recommendation(s) would be helpful for this client in reducing risk for type 2 diabetes mellitus? Select all that apply. A. Only select food items with no fat B. Take a cinnamon supplement C. Minimize the number of refined grains in the diet Eliminate sugary beverages and juices from the diet E. Double the usual amount of protein in the diet F. Increase the amount of dietary fiber

B.Take a cinnamon supplement Taking a cinnamon supplement may be beneficial as some studies suggest that cinnamon can help lower blood sugar levels and improve insulin sensitivity. C. Minimize the number of refined grains in the diet Minimizing the number of refined grains in the diet is advised because refined grains can have a negative impact on blood sugar control and may increase the risk of type 2 diabetes. D. Eliminate sugary beverages and juices from the diet Eliminating sugary beverages and juices from the diet is beneficial as these can lead to spikes in blood sugar levels and contribute to weight gain, which is a risk factor for type 2 diabetes. F. Increase the amount of dietary fiber Increasing the amount of dietary fiber is recommended because fiber can help manage blood sugar levels and reduce the risk of developing type 2 diabetes.

A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer? A. Thick, dry, and dark area on bilateral heels. B. Broken skin without evidence of undermining. C. Defined area of persistent redness over bone. D. Superficial sacral ulcer with defined margins.C

C. Defined area of persistent redness over bone. Rationale: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.

An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client who is prescribed bedrest with bedside commode use. The UAP reports to the nurse that the client's obesity makes it difficult to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? A. Advise the client to maintain bedrest to ensure safety. B. Instruct the UAP that all clients deserve equal care. C. Determine the client's level of mobility and need for assistance. D. Assign another UAP to care for the client.

C. Determine the client's level of mobility and need for assistance. Rationale: Determining the client's level of mobility and need for assistance will help in creating a safe and effective plan for transferring the client to the bedside commode.

The nurse manager is involved in agency restructuring. During this reengineering process, it is most important for the nurse to address which employee concern? A. New management's expectations. B. Changes in job descriptions. C. Employees' job security. D. Potential changes in employee benefits.

C. Employees' job security. Rationale: Job security is typically the most pressing concern for employees during restructuring, as it directly impacts their livelihood and future with the company.

A client who has borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by claiming the night shift nurse is aloof and expresses joy to see that, "My favorite nurse is on duty now." Which response is best for the nurse to provide to this client's dichotomous tendency? A. "What did the night nurse do that makes you think the nurse is aloof?" B. "Tomorrow I will talk to that nurse about how you were treated last night." C. "I am happy that you are getting better and will be able to go home." D. "I am glad you like me. Which nurse was acting aloof to you?"

C. I am happy that you are getting better and will be able to go home." Rationale: Expressing happiness for the client's improvement and discharge focuses on positive aspects and avoids engaging in potentially manipulative behavior.

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse? A. Monitoring for changes in stool color is important. B. Drinking grapefruit juice will reduce the effects of the medication. C. I should take the medication with antacids. D. If I experience any difficulty with breathing, I will report it.

C. I should take the medication with antacids. Rationale: Antacids can decrease the absorption of itraconazole, making it less effective. Patients should take itraconazole with food and an acidic drink, like cola or orange juice, but not with antacids.

A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report? A. Decreased bowel sounds. B. Increased respiratory rate. C. Increased abdominal girth. D. Decreased level of consciousness.

C. Increased abdominal girth Rationale: Increased abdominal girth is a common finding in cirrhosis due to ascites, which is the accumulation of fluid in the peritoneal cavity and can lead to significant weight gain.

A client experiencing recurrent episodes of depression expresses a desire to discontinue the prescribed antidepressant medication. The client reports feeling less depressed after taking the medication for the past few weeks but dislikes the side effects. What is the best response for the nurse to provide? A. Advise the client to discuss the medication's side effects with the healthcare provider. B. Remind the client that feeling better indicates the therapeutic effect of the medication. C. Inform the client that gradual tapering is necessary to discontinue the medication. D. Assure the client that the medication's side effects will likely dissipate over time.

C. Inform the client that gradual tapering is necessary to discontinue the medication. Rationale: Gradual tapering is the recommended approach to discontinuing antidepressants to minimize the risk of withdrawal symptoms and ensure the stability of the client's mental health.

The hospice nurse is teaching the family of a client receiving palliative care at home how to provide care. Which instruction should the nurse provide? A. Report any change in urine color. B. Maintain in high Fowler's position. C. Keep mucous membranes moist. D. Record the client's daily weights.

C. Keep mucous membranes moist. Rationale:Keeping mucous membranes moist helps prevent discomfort and is a key part of providing compassionate end-of-life care.

The nurse is caring for a client who arrives at the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. After obtaining vital signs, the nurse should implement which intervention? A. Initiate bilateral intermittent sequential pneumatic compression devices. B. Place an indwelling urinary catheter and measure strict intake and output. C. Notify the stroke team to assist with acute assessment and management. D. Administer aspirin to prevent further clot formation and platelet clumping.

C. Notify the stroke team to assist with acute assessment and management. Rationale: Notifying the stroke team is the most appropriate action as the patient's symptoms suggest a possible stroke, requiring urgent evaluation and management.

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? A. Assess body temperature. B. Monitor skin elasticity. C. Observe the aspiration site. D. Measure urinary output.

C. Observe the aspiration site. Rationale: Observing the aspiration site is crucial because thrombocytopenia increases the risk of bleeding, and the site must be monitored for any signs of hemorrhage.

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement? A. Obtain a urine specimen for culture and sensitivity. B. Instruct in effective techniques to cleanse the glans penis. C. Palpate the client's suprapubic area for distention. D. Advise the client to maintain a voiding diary for one week.

C. Palpate the client's suprapubic area for distention. Rationale: Palpating for suprapubic distention can provide immediate information about bladder fullness and potential urinary retention, which may require prompt intervention.

The patient is a 3-year-old male with a history of ventricular septal defect. He was born vaginally at 35 weeks and was in the neonatal intensive care unit (NICU) for 3 weeks due to poor feeding. He lives with his parents and an older sibling, who has no medical conditions. The patient is here for a follow-up visit. The nurse reviews the post catheterization orders. Which two orders would the nurse question? A. Place the child on a continuous cardiopulmonary monitor B. Check pedal pulses every 4 hours C. Point of care blood glucose D. Admit to the pediatric floor for observation E. Vital signs every 4 hours F. Check dressing every 15 minutes for 1 hour and then every hour for 24 hours G. NPO

C. Point of care blood glucose Point of care blood glucose testing every 6 hours may not be necessary unless the child has a history of diabetes or there was a specific concern during the procedure. This order should be clarified with the physician. G. NPO The order for NPO status might need to be questioned depending on the time expected before the child can eat or drink again, especially considering the child's age and the need for hydration and nutrition.

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider? A. Mild sedation. B. Dizziness reported after the initial dose. C. Somnambulism. D. A change in the sleep-wake cycle.V

C. Somnambulism. Rationale: Somnambulism, or sleepwalking, is a serious side effect that should be reported to the healthcare provider immediately. Ramelteon can cause people to engage in activities while not fully awake and have no memory of the activity afterward. This could include walking, driving, eating, or making phone calls, and poses a significant safety risk.

The nurse is assessing an older adult client who is having difficulty remembering events from earlier in the day and concentrating on the questions being asked. A family member shares that the client's home was recently sold and the client has just moved in with them. Which nursing response best promotes effective communication with the family? A. Delirium is often a sign of underlying mental illness, and institutionalization is often necessary. B. If the dementia is a result of Alzheimer's disease, it is often reversible even in the late stages. C. The client's delirium may be due to depression and is possibly reversible. D. The client is exhibiting symptoms of dementia, and because of age, it may be permanent.

C. The client's delirium may be due to depression and is possibly reversible. Rationale: Recognizing the possibility of delirium due to depression, which can be reversible, is a hopeful and constructive approach that encourages further evaluation and treatment options.

When performing suctioning for a client with a tracheostomy, which action should the nurse include? A. Apply a water-soluble lubricant to the catheter. B. Instill 3 mL of 0.9% sodium chloride before suctioning. C. Wear protective goggles while performing the procedure. D. Instruct the client to cough as the suction tip is removed.

C.Wear protective goggles while performing the procedure. Rationale: Wearing protective goggles is important to protect the nurse from potential splashes of bodily fluids during the suctioning process.

A parent asks the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae type b (Hib) conjugate vaccine. Which instruction should the nurse provide? A. Chewable children's aspirin will help prevent inflammation. B. Any level of fever is serious and should be reported right away. C. Keep the child home from daycare for the next two days. D. Apply a cool pack to the injection site to reduce discomfort.

D. Apply a cool pack to the injection site to reduce discomfort. Rationale: Applying a cool pack to the injection site is a common recommendation to reduce discomfort and swelling after vaccinations.

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care? Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)] Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)] A. Obtain a 12-lead electrocardiogram daily. B. Evaluate glucose levels before and after meals. C. Monitor and document strict intake and output. D. Assess the serum potassium level every 4 hours.

D. Assess the serum potassium level every 4 hours. Rationale: Frequent assessment of serum potassium levels is essential to evaluate the effectiveness of the dextrose and insulin therapy in lowering potassium levels.

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome indicates that the program was effective? A. New screening protocols were developed, validated, and implemented. B. More than half of at-risk clients were diagnosed early in their disease process. C. Clients who incurred disease complications promptly received rehabilitation. D. Average client scores improved on specific risk factor knowledge tests.

D. Average client scores improved on specific risk factor knowledge tests. Rationale: Improvement in client knowledge about specific risk factors as evidenced by test scores is a direct measure of the effectiveness of an educational prevention program. It indicates that clients have understood and potentially internalized the information necessary to prevent sexually transmitted diseases, which is the goal of primary prevention.

A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement? A. Assume care of the client and assign the PN to the care of a different client. B. Arrange for unlicensed assistive personnel to assist the PN during the procedure. C. Acknowledge that the PN has positioned the client safely and correctly. D. Demonstrate to the PN how to position the client more effectively for the procedure.

D. D. Demonstrate to the PN how to position the client more effectively for the procedure. Rationale: Demonstrating the correct positioning ensures the procedure can be performed effectively and safely, which is the nurse's immediate responsibility.

While the nurse is preparing a scheduled IV medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? A. Review the medical record for the date of insertion. B. Apply ice first, then a warm compress to the IV site. C. Document that the medication was not administered. D. Discontinue the painful IV after a new IV is inserted.

D. Discontinue the painful IV after a new IV is inserted. Rationale: If the IV site is painful, it may be indicative of infiltration, phlebitis, or another complication. The nurse should discontinue the painful IV and insert a new one at a different site to prevent further discomfort and potential harm to the client.

A client arrives for an annual physical exam and reports having calf pain. The client's health history includes peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms? A. Were your legs ever suddenly swollen, red, warm, and painful? B. Did you receive treatment for weeping ulcers on lower legs? C. Have you experienced ankle edema and varicose veins? D. Does the calf pain occur when walking short distances?

D. Does the calf pain occur when walking short distances? Rationale: Intermittent claudication, which is pain during walking that subsides with rest, is a hallmark of peripheral arterial disease and is an expected finding in clients with this condition.

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include a sodium of 129 mEq/L (129 mmol/L), a glucose of 54 mg/dL (2.97 mmol/L), and a potassium of 5.3 mEq/L (5.3 mmol/L). When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)], Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)], Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)] A. Broad-spectrum antibiotic. B. Regular insulin. C. Potassium chloride. D. Hydrocortisone.

D. Hydrocortisone. Rationale: Hydrocortisone is anticipated because it is a corticosteroid replacement therapy, which is essential for a patient with Addison's disease experiencing an adrenal crisis.

When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client's plan of care? A. Assess bilateral breath sounds. B. Palpate the suprapubic region for urinary retention. C. Review the client's daily medications. D. Initiate neurological monitoring every 2 hours.

D. Initiate neurological monitoring every 2 hours. Rationale: Initiating neurological monitoring every 2 hours is essential for a client with TIA to promptly identify any changes or progression in neurological status, which could indicate a stroke. This is the most important intervention to include in the plan of care for a client admitted with TIA. Neurological monitoring allows for immediate intervention if the client's condition worsens, potentially preventing further ischemic damage.

A client with bladder cancer had surgical placement of a ureter ileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately? A. Mucous strings floating in the drainage. B. Red edematous stomal appearance. C. Stomal output of 40 mL in the last hour. D. Liquid brown drainage from the stoma.

D. Liquid brown drainage from the stoma. Rationale: Liquid brown drainage from the stoma could indicate a problem such as an infection or bowel content leakage and should be reported immediately.

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care? A. measure body temperature B. assess skin turgor C.check for pedal edema D.observe the color of urine

D. Observe the color of urine. Rationale: Observing the color of urine is important as prasugrel can cause significant and sometimes fatal bleeding. Dark or bloody urine may be an early indicator of such bleeding.

The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes mellitus. He has a history of depression, which is treated with paroxetine 10 mg PO every day. The client also discloses that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's body mass index (BMI) is 28 kg/m2. Review H and P and laboratory results. Based on the laboratory data, the client has Select an option A.gestationaldiabetes B.hypoglycemia C. diabetes mellitus D. prediabetes related to Select an option A. fatty liver disease B. lack of insulin production C. impaired glucose tolerance D. occupational

D. Prediabetes Prediabetes is indicated by a fasting blood glucose level of 100 to 125 mg/dL (5.6 to 6.9 mmol/L)1. The client's level falls within this range, indicating that he has higher than normal blood glucose levels but not high enough to be classified as diabetes, hence prediabetes. Option 2 C. Impaired glucose tolerance is a condition where blood glucose levels are higher than normal but not high enough to be classified as diabetes. It is a characteristic of prediabetes and is indicated by the client's fasting blood glucose level.

Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis? A. Application of heat and cold therapy. B. Avoidance of foods containing purine. C. Immobilization of affected joints. D. Prevention through nutrition and exercise.

D. Prevention through nutrition and exercise. Rationale: Prevention through nutrition and exercise is the most comprehensive approach that aligns with health promotion and teaching for clients with rheumatoid arthritis. It includes educating clients on a balanced diet and physical activity to manage symptoms and improve overall health.

An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement? A. Encourage the client to lie as still as possible during the assessment. B. Ask the client how often episodes of sundowning are experienced. C. Assist the client with values clarification about end-of-life care options. D. Question the client about the frequency of falls in recent months.

D. Question the client about the frequency of falls in recent months. Rationale: Questioning the client about the frequency of falls is crucial as it helps assess the risk of future falls and the need for interventions to prevent them, which is a key component of functional assessments in rehabilitation settings.

The nurse is teaching a client with early osteoporosis the importance of including vitamin D with calcium supplements. Which information is most important for the nurse to provide to encourage the client's compliance in the management of progressing osteoporosis? A. Avoiding the use of sunscreen is important for adequate vitamin D synthesis. B. Vitamin D combined with calcium is balanced with phosphorus for absorption for strong bones. C.Calcium uses vitamin D that is produced in the skin by exposure to sunshine D.Adding daily Vitamin D with oral calcium supplements promotes absorption of calcium into bone

D.Adding daily Vitamin D with oral calcium supplements promotes absorption of calcium into bone. Rationale: Emphasizing that vitamin D enhances calcium absorption into the bone provides a clear rationale for the client to comply with the supplementation regimen.

The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes mellitus. He has a history of depression, which is treated with paroxetine 10 mg PO every day. The client also discloses that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's body mass index (BMI) is 28 kg/m2. Review H and P and laboratory results. Drag from the Word Choices to complete the sentence. "For the nutrition education portion of the visit, the nurse focuses on Select an option A. Decreasing portion sizes B. Avoiding potassium rich foods C. eating only plant-based foods and Select an option D. Replacing refined sugar with honey or molasses E. Choosing a well-rounded diet F. Eliminating carbohydrates .

Dropdown Group 1: Decreasing portion sizes Dropdown Group 2: choosing a well-rounded diet Rationale Choice A Reason: Decreasing portion sizes can help manage calorie intake and contribute to weight loss, which is beneficial for individuals with prediabetes or diabetes. Proper portion control is also essential for maintaining blood sugar levels within the target range. Choice D Reason: Choosing a well-rounded diet ensures that all necessary nutrients are included, which is important for overall health and can help manage blood sugar levels. A balanced diet for diabetes should include a variety of foods from all food groups.

The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes mellitus. He has a history of depression, which is treated with paroxetine 10 mg PO every day. The client also discloses that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's body mass index (BMI) is 28 kg/m2. Review of History, Physical, and Laboratory Results Based on the findings, indicate whether each represents a modifiable risk factor, a non-modifiable risk factor, or is unrelated to type 2 diabetes mellitus. A. Body mass index (BMI) of 28 kg/m² B. High-density lipoprotein (HDL) of 43 mg/dL (1.11 mmol/L) C. Sister with type 2 diabetes mellitus D. Occupational fume exposure E. Cannabis use

Modifiable risk factors A. Body mass index (BMI) of 28 kg/m² B. High-density lipoprotein (HDL) of 43 mg/dL (1.11 mmol/L) Nonmodifiable risk factors C. Sister with type 2 diabetes mellitus Unrelated D. Occupational fume exposure E. Cannabis use Rationale: Choice A Reason: A BMI of 28 kg/m² is considered overweight and is a modifiable risk factor for type 2 diabetes mellitus. Weight loss through diet and exercise can reduce the risk. Choice B Reason: An HDL level of 43 mg/dL (1.11 mmol/L) is slightly below the recommended range and is a modifiable risk factor. Increasing HDL can be achieved through lifestyle changes such as exercise and dietary adjustments. Choice C Reason: Having a sister with type 2 diabetes mellitus is a non-modifiable risk factor as it is related to genetic predisposition. Choice D Reason: Occupational fume exposure is generally considered unrelated to the development of type 2 diabetes mellitus. Choice E Reason: Cannabis use is typically unrelated to type 2 diabetes mellitus, though research on its long-term metabolic effects is ongoing.